ECG Básica

Hipertrofia y Crecimiento de Cavidades

atrial abnormality. However, little evidence is available
Crecimientos Auriculares
regarding the accuracy of ECG criteria for combined atrial
abnormality.

Recommendations
1. Abnormal P waves should usually be referred to as right
or left “atrial abnormality” rather than enlargement,
overload, strain, or hypertrophy.
2. Multiple electrocardiographic criteria should be used to
recognize atrial abnormalities.
3. Intraatrial conduction delay should be recognized as a
category of atrial abnormality applicable particularly
to instances where P-wave widening is not accompanied
e258 Circulation March 17, 2009
by increased amplitude of right or left atrial components.
of the P-wave vector.64 A tall upright P wave in lea
Crecimientos Auriculares
cardiographic valvular heart disease
support the
hanges on the
other condi-
II

are directed
of the P wave.
sociated with
III
gh the overall
A tall P wave
own as the P

atrial enlarge- aVF

ological find-
ic obstructive
ngenital heart
ogy of Fallot.
are associated Figure 12.1 Large P waves in leads II, III, and aVF (P pulmonale).
eflected in the
of right atrial
pertrophy are
Right ventricular hypertrophy is associated with pulmonary
e may appear
 valvular disease,

he presence of
depolarisation
he P wave. The
the presence of
n the late por-
al depolarisation
sation may be
the P wave. The
wave.
n in the late por- Figure 13.1 Biphasic P wave in V1. The large negative deflection indicates
ht atrial forces
risation may be left atrial abnormality (enlarged to show detail).
ive deflection;
wave.
osteriorly,
ight atrial pro-
forces Figure 13.1 Biphasic P wave in V1. The large negative deflection indicates
eflection (>1 left atrial abnormality (enlarged to show detail).
sitive deflection;
lity. Prolonga-
posteriorly, pro-
often found( >
deflection in1
wavesProlonga-
mality. may be
shtoften
asynchrony
found in
a pronounced
P waves may be
gests left atrial
ight asynchrony
er, a pronounced
uggests
ertrophy left may
atrial
nomenon. Left
pertrophy
ystemic hyper-may Figure 13.2 P mitrale in lead II. P mitrale is a P wave that is abnormally
henomenon. Left notched and wide and is usually most prominent in lead II; it is commonly
hypertrophic seen in association withinmitral
systemic hyper- Figure 13.2 P mitrale lead II.valve disease,
P mitrale is a Pparticularly
wave that ismitral stenosis
abnormally
(enlarged to show
notched and wide detail).
and is usually most prominent in lead II; it is commonly
nd hypertrophic seen in association with mitral valve disease, particularly mitral stenosis
(enlarged to show detail).

f left ventricu-
Crecimiento Auricular Derecho

1.-Aumento del Voltaje en las derivaciones del plano frontal,

con ondas p Picudas y de ramas simétricas, > de 2.5mm.

2.-Duración normal < o igual a 0.11s

3.-Aumento de voltaje en precordiales salvo V1 que es (++-)

 Crecimiento Auricular Derecho

Enfermedades Pulmonares Crónicas

Cardiopatías Congénitas

Hipertensión Arterial Pulmonar

 Crecimiento Auricular Izquierdo

P ancha ≥ 0.12 seg

Bimodal en D2-D3-aVF

Bifásica con predominio negativo en V1

 Crecimiento Auricular Izquierdo

Estenosis e Insuficiencia Mitral

Hipertensión Arterial

Miocardiopatías

Estenosis Aórtica
Hipertrofia Ventricular
Table 13.2 Left ventricular hypertrophy.

Voltage criteria
Limb leads
! R wave in lead I plus S wave in lead III > 25 mm
! R wave in lead aVL > 11 mm
I
! R wave in lead aVF > 20 mm
! S wave in lead aVR > 14 mm

Precordial leads
! R wave in leads V4, V5, or V6 > 26 mm
! R wave in leads V5 or 6 plus S wave in lead V1 > 35 mm
! Largest R wave plus largest S wave in precordial leads > 45 mm

Non-voltage criteria
! Delayed ventricular activation time ≥ 0.05 s in leads V5 or V6 > 0.05 s
! ST segment depression and T wave inversion in the left precordial leads
II

The specificity of these criteria is age and sex dependent

 I
Typical repolarisation changes seen in left ventricular hypertrophy
are ST segment depression and T wave inversion. This “strain” pattern

II

III

Figure 13.5 Left ventri

who presented with he
(gradient 125 mm Hg).
ventricular hypertrophy
Figure 13.3 Left ventricular hypertrophy with strain (note dominant R wave scoring system is used,
and repolarisation abnormality). even though none of th
 > 25 mm
I aVR V1 V4

m
n lead V1 > 35 mm
precordial leads > 45 mm

.05 s in leads V5 or V6 > 0.05 s

version in the left precordial leads II aVL V2 V5

ex dependent

ft ventricular hypertrophy, but

ng systems based on these crit-
though they are highly specific
mits their use. III aVF V3 V6

ngs
of left ventricular hypertrophy
ria or non-voltage criteria.
osis of left ventricular hypertro-
d under 40. Voltage criteria lack Figure 13.4 Left ventricular hypertrophy in patient who had presented with
young people often have high chest pain and was given thrombolytic therapy inappropriately because of
he absence of left ventricular the ST segment changes in V1 and V2.
de QRS complexes are seen in
 people often have high chest pain and was given thrombolytic therapy inappropriately because of
nce of left ventricular the ST segment changes in V1 and V2.
S complexes are seen in
uch as ST segment and
made with confidence. I aVR V1 V4
ventricular hypertrophy
sion. This “strain” pattern

II aVL V2 V5

III aVF V3 V6

Figure 13.5 Left ventricular hypertrophy without voltage criteria—in a man

rain (note dominant R wave
who presented with heart failure secondary to severe aortic stenosis
(gradient 125 mm Hg). The ST segment changes are typical for left
ventricular hypertrophy and there is evidence of left atrial enlargement. If the
scoring system is used, these findings suggest left ventricular hypertrophy
even though none of the R or S waves meets voltage criteria.
 III
Table 12.1 Diagnostic criteria for right ventricular hypertrophy.

(Provided the QRS duration is less than 0.12 s)

! Right axis deviation of + 110° or more
! Dominant R aVF
wave in lead V1
! R wave in lead V1 ≥ 7 mm

Supporting criteria
! ST segment depression and T wave inversion in leads V1 to V4
! Deep S waves in leads V5, V6, I, and aVL
Figure 12.1 Large P waves in leads II, III, and aVF (P pulmonale).

51
Right ventricular hypertrophy is associated with pulmonary
hypertension, mitral stenosis, and less commonly, conditions such
as pulmonary stenosis and congenital heart disease
2/7/2008 12:05:43 PM
 I V1

II V2

III V3

Figure
Lead V1 12.2 Right
lies closest to ventricular hypertrophy
the right ventricular myocardium and is Table 12.2 Conditions associ
secondary
therefore best to pulmonary
placed to detectstenosis
the changes(note
of the
right ventricular
! Right ventricular hypertrop
dominantand
hypertrophy, R wave in leadR V1,
a dominant wavepresence
in lead V1ofis right
observed. The
! Posterior myocardial infarct
atrial hypertrophy,
increased rightward forcesright
are axis deviation,
reflected and leads, in the
in the limb ! Type A Wolff-Parkinson-Wh
form of right
T wave axis deviation.
inversion Secondary
in leads changes may be observed
V1 to V3). ! Right bundle branch block
in the right precordial chest leads, where ST segment depression
A tall R wave in lead V1 is no
and T wave inversion are seen.
Table 12.2 Conditions associated with tall R wave in lead V1.

! Right ventricular hypertrophy

! Posterior myocardial infarction
! Type A Wolff-Parkinson-White syndrome
! Right bundle branch block

A tall R wave in lead V1 is normal in children and young adults

Table 12.3 Conditions associated with right axis deviation.

! Right ventricular hypertrophy

! Left posterior hemiblock
! Lateral myocardial infarction
! Acute right heart strain

Right axis deviation is normal in infants and children

 ry
er- Table 12.4 Electrocardiographic abnormalities found in acute pulmonary
th embolism.
ht
! Sinus tachycardia
! Atrial fl utter or fi brillation
! S1, Q3, T3 pattern
! Right bundle branch block (incomplete or complete)
! T wave inversion in the right precordial leads
! P pulmonale
th ! Right axis deviation
as
ve
ce
in
V1 V4

V2 V5
monary
I
derlying
gs used
monary
I
erlying
gs
in used
and
multi-
in and
tricular
multi-
tricular III

III

mbolism
effects
bolism
ent. The
effects
Figure 12.5 Sinus tachycardia and S1, Q3, T3 pattern in patient with
gnt.is The
also pulmonary embolus (diagram scaled up).T3 pattern in patient with
Figure 12.5 Sinus tachycardia and S1, Q3,
ntis with
also pulmonary embolus (diagram scaled up).
nt with
ctrocar-
trocar-
y artery The S1, Q3, T3 pattern is seen in about 12% of patients with a
artery
his may The S1, Q3,pulmonary
T3 pattern embolus
is seen in about 12% of patients with a
his may massive
e inver- massive pulmonary embolus
e inver-
own S1,
own S1,
 I aVR V1 V4

II aVL V2 V5

III aVF V3 V6

54 ABC of Clinical Electrocardiography

Figure 12.6 Preoperative electrocardiogram in otherwise healthy 38 year old man.

I aVR V1 V4

_012.indd 53 2/7/2008 12:05:44 PM

II aVL V2 V5

III aVF V3 V6

Figure 12.7 Acute pulmonary embolism:

10 days postoperatively the same patient
developed acute dyspnoea and hypotension
(note the T wave inversion in the right
precordial leads and lead III).